Surgical culture

I just started week 2 on an inpatient general surgery service. My desire to ever venture into anything surgical has diminished even further. If first impressions are worth anything, then the surgical stereotypes ring true.

I was in the OR today with an old school surgeon. For 3 hours, the surgical resident and I put up with jokes that in any other setting would be misogynistic bordering on harassment. During the case, he tells me, "any attention [paid to the medical student] is good attention, even bad...the worst thing is to be ignored." True, but I think the implied message is I should appreciate that he is even talking to me. Awesome - I'm so grateful that this surgeon is even acknowledging my presence. Perhaps I should turn into a lump of clay. Later, he makes fun of our curriculum in cultural competency, which ironically, he may benefit from.

Rounds work something like this: there's the chief resident, the intern, the night intern, a surgical PA, and the med student. On each bay, the med student pulls all the charts and opens the chart to the proper page so the daily progress note can be inserted quickly. Then I hurry into the room, glove as quickly as possible, and hand dressings to the chief resident, whose path we've cleared so that she can enter the room first. During each 1.2 minute visit with each patient, the chief resident does all of the talking while the rest of us stand silent with gloves on ready to assist. I have never seen anything so overtly hierarchical. No teaching goes on. No one on my team has voluntarily taught unless I've asked a question and even then, the question is either fired back (which I don't mind) or answered very tersely. At times I wonder how surgical residents learn anything. There are no daily noon conferences, no morning reports, and no teaching on rounds.

I suppose I have it good though. My fellow medical student is being scutted out by her intern, who sends her down to the PACU and then to several floors throughout the hospital to collect vitals - on the entire list of patients, not just hers. Seriously, tell me why vitals are not electronically transmitted? It seems incredibly inefficient to run around to several floors, hunt down a paper vitals binder, and write down the vitals which were probably not even taken properly. It is a mess. Thank god my intern is an angel, apologizes for the scut, and sends me home at a decent hour.

Also, thank goodness this rotation is at the end of my third year. I would have been so jaded and disillusioned by now had this occurred earlier.

Why is the pH of normal saline 5.5?

My anesthesiology preceptor posed this question to me last week. He asked, "What do think the pH of normal saline is?" Thinking that it's a reaction between a strong acid and strong base, i.e. HCl + NaOH <--> NaCl + HOH, I said it must be neutral or pH 7. When we actually obtained a bag of normal saline, the label said pH 4.7-5.5 (or something like that), basically acidic, right?

I could not figure out how NS could be acidic and for once, Google failed! Some online sources cited the plastic packaging, which they claimed leeched acidic compounds into the saline. Or, they explained the acidity through dissolved CO2.

The answer turned out to be deceptively simple, one I never could have reached because of course, I've forgotten all my basic chemistry. Think about the definition of pH. pH = -log [H+] How does something become pH 7, for strong acids/bases? It needs to have a measured H+ concentration of 10^-7. Turns out, the salt in NS alters the dissociation constant of water such that there is more measured H+ dissociated than OH-. It is still "neutral," but the pH is calculated to be lower.

ED shift

I'm awake after napping over four hours after an ED shift last night, which was totally awesome. Not only did I have a fantastic resident, I was on the overnight shift with my one of my best friends, making it all the more fun.

Here's what I got to do/witness:
- Watch a trauma code (fortunately, the guy had some injuries but was stable) and suture his facial lacs (first time suturing from start to finish!)
- Witness a partial complex seizure and pull an intraosseous line. An "IO" line is a means of delivering fluids when an IV cannot be placed. It screws directly into the medial side of the tibial bone.
- Drain a perirectal abscess (ouch but the guy felt so much better afterward and was so grateful)
- Evaluate pt with abdominal pain who turned out to have gallstone pancreatitis
- Evaluate pt also with abdominal pain. Dx: rectus sheath hematoma requiring angioembolization
- Evaluate pt s/p MVA who had an impressive displaced thoracic spine fracture. Admitted to neurosurgery for stabilization in the morning
- Head down to the OR to catch the beginning of an emergency leg amputation for a pt with necrotizing fascitis. The pt was covered head to toe in purpura, on a thousand pressors, auto anti-coagulating, basically a mess...incredibly sad. The team kept the OR extremely warm to prevent hypothermia, as the pt could longer autoregulate his own temperature.

All in a night's work!

Last week, I saw a guy with Gardner's syndrome and two trauma codes, where I got to place a suture (just one haha) in one man's ear for a nasty ear laceration.

Novelty is exciting and I'm finally feeling that I'm getting to learn how to do stuff with my hands. Appropriate for a surgery rotation, I suppose.

Disconnected

Hmm. I feel really disconnected from the world.  We had a snowstorm like half the country earlier this week.  While classes, schools, and most offices closed for the day, for us, it was normal day.  After all, it's always sunny and 72 degrees in the hospital. Even the roads clear super fast around the hospital so the only remnants of the storm are man-high piles of dirty snow in parking lots.

This week, I'm on ortho and so far, I've seen a total hip, knee, and laminectomy.  There's some crazy drilling and hammering action in the OR.  Cool for a few days, but I am again reminded why I will not be a surgeon.  Also, ortho has got to be the most testosterone-driven field I have yet experienced.  The ortho workroom is mixture between a boy's frat and locker room. At least it doesn't smell bad.  But I exaggerate - I'm with a great resident this week who loves teaching, and I've learned more about MSK this week than my third year combined.

It's like falling in love

From a email today from one of my college mentors, a physician and writer with heaps of wisdom and a sense of humor to match:
"Nothing is more fun [than clinical medicine] than falling in love."

Indeed, Dr. L, indeed.

Immersion

“As my life grows richer within the hospital, it becomes less so outside of it.”  ~fellow third-year classmate.

In those words, my classmate alluded to ever-elusive work-life balance and challenge of maintaining relationships with friends and loved ones while devoting full days and nights to clinical work.  It is not so much the frank amount of time spent in the hospital (although the 80+ hour weeks on inpatient months certainly contributes),  it is the emotional energy required to be in a position of constantly caring.  Indeed, there are days where I am so drained by my patient interactions that I simply haven’t any more emotional energy left to expend.  Sometimes, at the end of the day, I simply cannot give any more of myself to others.   Our relationships suffer because of it.   

Another classmate, in tears, described learning that her friend had died suddenly of cancer during her surgery clerkship.  Our school’s policy mandates no absences except for immediate family emergencies.   Forced to miss the funeral, she clearly was filled with guilt and sorrow.   All of us entered medicine understanding full well that we would have to make sacrifices.   Yet it does not make it any easier. 

Then there is the emotional disconnect.   As I grow increasingly at home in the hospital, I become more isolated from those outside of it.  I’ve noticed it with my friends and even more so with my parents.  My parents are interested; they want to understand.  In our weekly conversations they will ask, “How are you doing? What stories do you have?”   Where do I even begin?   My parents are not physicians, and luckily, have little experience with the medical system.  Even the most superficial conversations require layers upon layers of explanation (think: a resident is a doctor who has an MD but is still training.).  I don’t blame them – how could they, or for that matter, others who have not experienced the immersion that is medical school, begin to understand what it is like?  Many times, we will just end up talking past each other, and that is okay.  I am still their daughter, and it is their concern and willingness to ask and listen that matters the most.

Would I trade this for something else?  No way.  I am truly happier this year than my first two years combined.   Sure, I have good days and awful days, but I am stimulated and challenged every day by what I learn.  I am excited to talk to my patients, to understand their experiences, and learn about their diseases.   I feel the camaraderie of working within a team and a strong sense of solidarity with my fellow classmates.   I see myself growing and changing in ways that I could never have predicted.  Eight months into my third year, I have become tougher and more real, yet I remain an idealist.

Tough

Today was tough - the kind of tough that makes you want to call your mom, dad, sister right after work and tell them that you love them.

We told a lady today that she had stage 4 lung cancer and that there's no cure.  She has a teenage daughter who recently started sleeping with her parents because she wants to make sure that their hearts are still beating at night. The minute we reached the stage 4 part, she developed that deer in the headlights look.  Pure shellshock.   I watched as her husband's eyes glazed over, as he reached over to squeeze his wife's hands, as his wife struggled to maintain composure.  "4 weeks ago, I was lifting weights," she cried.   And now this.  Sometimes, medicine sucks.